构建电子病历逻辑校验原则对医院国际疾病分类编码正确率的影响  

Influence of Constructing the Logic Verification Principle of Electronic Medical Record on the Accuracy Rate of International Classification of Diseases Coding in Hospitals

作　　者：董丽霞[1] 冯解傻[1] 梁莹 Dong Lixia;Feng Jiesha;Liang Ying(Medical Record Management Department of Gaozhou People's Hospital,Gaozhou 525200,Guangdong Province,China)

机构地区：[1]高州市人民医院病案管理科,广东高州525200

出　　处：《中外医药研究》2024年第9期162-164,共3页JOURNAL OF CHINESE AND FOREIGN MEDICINE AND PHARMACY RESEARCH

摘　　要：目的:分析构建电子病历逻辑校验原则对医院国际疾病分类(ICD)编码正确率的影响。方法:选取2021年1月—2022年12月高州市人民医院归档的220000份电子病历及作为研究对象,其中2021年1—12月112000份,2022年1—12月108000份。筛查2021年1—12月违反ICD编码逻辑规则的电子病历,分析错误原因,制定适合高州市人民医院的电子病历ICD逻辑校验原则。将ICD逻辑校验原则应用于2022年1—12月住院病案首页编码工作中。比较2021年及2022年住院病案首页ICD编码填写正确率及住院病案首页数据质量。结果:2022年ICD编码正确率高于2021年,差异有统计学意义(P<0.001)。2022年住院病案首页数据质量评分高于2021年,差异有统计学意义(P<0.001)。结论:构建电子病历逻辑校验原则可减少逻辑编码错误率,提高住院病案首页数据质量。Objective:To analyze the influence of constructing the logic verification principle of electronic medical record on the accuracy of ICD coding in hospitals.Methods:A total of 220000 electronic medical records archived in Gaozhou People's Hospital were selected as the research objects from January 2021 to December 2022,including 112000 from January to December 2021 and 108000 from January to December 2022.To screen the electronic medical records violating the ICD coding logic rules from January to December 2021,analyze the causes of errors,and formulate the ICD logic verification principles for the electronic medical records suitable for Gaozhou People's Hospital.The ICD logic check principle was applied to the coding of the first page of inpatient medical records from January to December 2022.The accuracy rate of ICD code filling and the data quality of the first page of inpatient medical records in 2021 and 2022 were compared.Results:The ICD coding accuracy in 2022 was higher than that in 2021,and the difference was statistically significant(P<0.001).The data quality score of the first page of inpatient medical records in 2022 was higher than that in 2021,and the difference was statistically significant(P<0.001).Conclusion:Establishing the logical verification principle of electronic medical records can reduce the error rate of logical coding and improve the data quality of the first page of inpatient medical records.

关 键 词：电子病历 质量控制系统 逻辑校验 国际疾病分类编码 

分 类 号：R197.323[医药卫生—卫生事业管理]